Post-COVID-19 condition: current evidence and unanswered questions
Authors: Olufemi Erinoso
Journal: The Lancet Global Health (2022)

As of July 2022, over 555 million cases of COVID-19 have been recorded globally, with more than 8·5 million confirmed cases reported in the African region.1Center for Systems Science and Engineering at Johns Hopkins UniversityCOVID-19 dashboard.https://coronavirus.jhu.edu/map.htmlDate accessed: July 10, 2022Google Scholar, 2WHO Regional Office for AfricaCOVID-19 (WHO African region).https://who.maps.arcgis.com/apps/opsdashboard/index.html#/0c9b3a8b68d0437a8cf28581e9c063a9Date accessed: July 10, 2022Google Scholar Various studies have been published in the past 2 years identifying persisting symptoms in individuals who had COVID-19 in different countries across the globe.3Jin H Lu L Fan H Global trends and research hotspots in long COVID: a bibliometric analysis.Int J Environ Res Public Health. 2022; 193742Google Scholar On the basis of this emerging condition—persisting symptoms linked to COVID-19 extending past the acute phase of infection—the UK's National Institute for Health and Care Excellence (NICE) published a guideline for clinicians on the long-term effects of COVID-19.4NICECOVID-19 rapid guideline: managing the long-term effects of COVID-19.https://www.nice.org.uk/guidance/ng188Date accessed: July 10, 2022Google Scholar The NICE guideline goes beyond clinical guidelines and defines the terms associated with these persistent signs and symptoms. The guideline distinguishes between the terminologies long COVID and post-COVID-19 condition, formerly used interchangeably. The term long COVID now refers to signs and symptoms that continue after acute COVID-19 disease (4–12 weeks),4NICECOVID-19 rapid guideline: managing the long-term effects of COVID-19.https://www.nice.org.uk/guidance/ng188Date accessed: July 10, 2022Google Scholar while the term post-COVID-19 condition (PCC) refers to signs and symptoms that develop during or after COVID-19 disease that continue for more than 12 weeks and cannot be explained by an alternative diagnosis.4NICECOVID-19 rapid guideline: managing the long-term effects of COVID-19.https://www.nice.org.uk/guidance/ng188Date accessed: July 10, 2022Google Scholar As the number of COVID-19 cases and survivors grows, the burden of PCC will also increase. Understanding the epidemiology and associated factors for PCC across diverse populations is crucial as the world transitions from the acute phase of the pandemic to a longer-term chronic phase. In The Lancet Global Health, Murray Dryden and colleagues prospectively investigate the prevalence and risk factors associated with PCC among individuals admitted to hospital with laboratory-confirmed SARS-CoV-2 infection in South Africa.5Dryden M Mudara C Vika C et al.Post-COVID-19 condition 3 months after hospitalisation with SARS-CoV-2 in South Africa: a prospective cohort study.Lancet Glob Health. 2022; 10: e1247-e1256Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar Participants aged 18 years or older were followed up by telephone at 1 month and 3 months after hospital discharge and assessed with use of a standardised questionnaire for the evaluation of symptoms, functional status, health-related quality of life, and occupational status. Of the 3094 participants who were selected and contacted for enrolment, 2410 (77·9%) consented to participate in the study at 1 month after discharge and of these, 1873 (77·7%) completed the 3-month follow-up. Dryden and colleagues' study validates and adds to the literature on PCC and persisting COVID-19-related signs and symptoms globally. More so, because of the dearth of literature in the African region,3Jin H Lu L Fan H Global trends and research hotspots in long COVID: a bibliometric analysis.Int J Environ Res Public Health. 2022; 193742Google Scholar, 6Osikomaiya B Erinoso O Wright KO et al.'Long COVID': persistent COVID-19 symptoms in survivors managed in Lagos State, Nigeria.BMC Infect Dis. 2021; 21: 304Crossref PubMed Scopus (29) Google Scholar the study adds valuable knowledge by using a relatively large database to provide information on PCC in the region. Furthermore, considering the potential for phenotypic and genetic effects on the characteristics of COVID-19 disease, the racially and ethnically diverse population in South Africa expounds our understanding of PCC in this unique setting. Dryden and colleagues report a prevalence of 82·1% for long COVID and 66·7% for PCC in South Africa. The most common PCC symptoms were fatigue (50·3%) and shortness of breath (23·4%). Additionally, being female and being admitted to an intensive care unit (ICU) were associated with a higher likelihood of PCC signs and symptoms. Furthermore, individuals aged 40–64 years (compared with those younger than 40 years) had increased odds of new or worse disability. Within the context of current research, Dryden and colleagues validate previous findings about PCC within and outside the African region.6Osikomaiya B Erinoso O Wright KO et al.'Long COVID': persistent COVID-19 symptoms in survivors managed in Lagos State, Nigeria.BMC Infect Dis. 2021; 21: 304Crossref PubMed Scopus (29) Google Scholar, 7Lopez-Leon S Wegman-Ostrosky T Perelman C et al.More than 50 long-term effects of COVID-19: a systematic review and meta-analysis.Sci Rep. 2021; 1116144Crossref PubMed Scopus (455) Google Scholar The study findings also provide additional considerations for practice. For example, findings centred on the effect of PCC on different health domains such as functionality, health-related quality of life, and occupational status showed the need for a multifaceted approach to management. This approach should include managing the physical, mental, and cognitive effects of PCC in individuals. Additionally, several recommendations, such as the Stanford Hall Consensus statement,8Barker-Davies RM O'Sullivan O Senaratne KPP et al.The Stanford Hall consensus statement for post-COVID-19 rehabilitation.Br J Sports Med. 2020; 54: 949-959Crossref PubMed Scopus (252) Google Scholar provide examples of rehabilitation approaches in multidisciplinary domains for individuals with PCC that can be modified on the basis of the specificities of local health settings. Other findings in Dryden and colleagues' study5Dryden M Mudara C Vika C et al.Post-COVID-19 condition 3 months after hospitalisation with SARS-CoV-2 in South Africa: a prospective cohort study.Lancet Glob Health. 2022; 10: e1247-e1256Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar that provide important considerations for health systems include the relatively high proportion (44·7%) of individuals with PCC who consulted with a general practitioner or primary health-care clinic. This finding suggests the need for the inclusion of primary health-care clinics in implementing PCC interventions. More so, over half of individuals in the study were employed full-time before developing COVID-19 and, among some who developed PCC, the condition altered their employment status. The effect on employment indicates the potential impact that PCC can have on the economy if timely interventions are not designed and implemented. Despite these findings by Dryden and colleagues, several questions remain unanswered. For example, the mechanism of PCC and persisting symptoms in individuals who had COVID-19 remains unknown. For instance, what pathophysiological mechanism drives this pathway in individuals who were admitted to ICU and ultimately developed PCC? Is it attributed to ICU-related post-traumatic stress or post-intensive care syndrome,9Kaseda ET Levine AJ Post-traumatic stress disorder: a differential diagnostic consideration for COVID-19 survivors.Clin Neuropsychol. 2020; 34: 1498-1514Crossref PubMed Scopus (85) Google Scholar the pulmonary injury from COVID-19, or a combination of both factors? Additionally, can the pattern of multiorgan symptoms or signs (ie, fatigue and shortness of breath) be explained by a resolving or different inflammation, persistent subacute SARS-CoV-2 infection, or a consequence of immunomodulatory therapy? Furthermore, the trajectory of PCC is not fully understood, as most studies have not assessed the condition for up to 12 months.7Lopez-Leon S Wegman-Ostrosky T Perelman C et al.More than 50 long-term effects of COVID-19: a systematic review and meta-analysis.Sci Rep. 2021; 1116144Crossref PubMed Scopus (455) Google Scholar As a step in the right direction, the US National Institutes of Health this year provided nearly US$470 million in funding to the Researching COVID to Enhance Recovery Initiative to help understand the trajectory and clarify the link between COVID-19 and the multiorgan effects of PCC.10Researching COVID to Enhance Recovery InitiativeMaking progress toward recovery.https://recovercovid.org/researchDate: 2022Date accessed: July 10, 2022Google Scholar Furthermore, no studies have assessed the outcome of multidisciplinary interventions in low-income and middle-income country (LMIC) settings, which account for a large proportion of COVID-19 cases globally. Identifying cost-effective and evidence-based multidisciplinary interventions is especially crucial for the sub-Saharan Africa region because of the limited capital and human resources available. Also, this region's relatively high prevalence of infectious diseases and malnutrition (competing for limited resources in the health system) suggests that interventions in high-income settings might not be readily applicable in LMIC settings. Another overarching question is how clinicians and researchers can work across disciplines and effectively communicate to address cross-disciplinary approaches to managing PCC. How can we design studies using a standardised approach across diverse settings with unequal health-care resources and access to measure the outcome of PCC interventions at the population level? The key findings from Dryden and colleagues' study are twofold. First, two-thirds of individuals who had COVID-19 in their cohort reported PCC symptoms that affected their functional status, quality of life, and occupational status. Second, women and individuals admitted to ICU had an increased likelihood of reporting PCC. Findings from this study indicate the urgent need for research clarifying the link between COVID-19 status and persisting or new multiorgan PCC signs or symptoms, as well as the need for concerted efforts to develop an evidence-based multidisciplinary management strategy for individuals affected by the condition. I declare no competing interests. Post-COVID-19 condition 3 months after hospitalisation with SARS-CoV-2 in South Africa: a prospective cohort studyMost participants in this cohort of individuals previously hospitalised with COVID-19 reported persistent symptoms 3 months after hospital discharge and a significant impact of PCC on their functional and occupational status. The large burden of PCC symptoms identified in this study emphasises the need for a national health strategy. This should include the development of clinical guidelines and training of health-care workers for identifying, assessing, and caring for patients affected by PCC; establishment of multidisciplinary health services; and provision of information and support to people who have PCC. Full-Text PDF Open Access